September 2009




Outcomes following open-globe injuries

by Tony Realini, M.D.


Work-related injuries are common, as is traumatic glaucoma

The old adage “an ounce of prevention is worth a pound of cure” is particularly true in the case of ocular trauma. Most ocular injuries are preventable, and outcomes of ocular trauma are typically unfavorable. In particular, traumatic open-globe injuries can be catastrophic, resulting in significant loss of vision, blindness, and even loss of the eye.

To provide new insight into the nature and outcomes associated with open-globe injuries, a multidisciplinary team representing several institutions in the Boston area recently conducted a 10-year analysis of over 800 such injuries.

Work-related injuries

“Eye injuries are common in the workplace,” said Justin Kanoff, M.D., Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston. “There were 36,630 in 2004 alone.”

Further, the National Eye Trauma System Registry has shown that 22% of all open-globe injuries occur in the workplace, he said.

“We evaluated the characteristics and outcomes of patients treated for open-globe injuries sustained at work and compared these findings to patients injured outside of work,” said Dr. Kanoff.

Of 813 open-globe injuries occurring during the 10-year period studied, 146 occurred in the workplace, said Dr. Kanoff.

“We found that 98% of the patients injured at work were men, and the average age of these patients was about 36 years,” he said. “The majority—60%—presented for evaluation within six hours of the injury, while 17% took greater than 12 hours to seek medical attention.”

He added, “The most common mechanism of injury was penetrating trauma, which was seen in 56% of eyes.” Further, he said, 38 patients had an intraocular foreign body. Compared to non-work-related open-globe injuries, both penetrating injuries and intraocular foreign bodies were more common in eyes with work-related injuries.

Interestingly, work-related open-globe injuries seemed to be less severe than injuries occurring outside the workplace. “Both the pre-operative and final best-corrected visual acuity were better in the work-related group,” said Dr. Kanoff. In this group, 82% of eyes achieved a final acuity of 20/200 or better, he said.

“Based on the frequency of work-related ocular injuries, employers should have a formalized mechanism for ensuring that employees receive prompt medical attention,” said Dr. Kanoff. “A significant proportion of patients’ presentations were delayed more than 12 hours, suggesting the need for better education and workplace protocols to address these injuries.”

Eye injuries in women

“Very few studies have examined eye injuries and women,” said Sahar Kohanim, M.D., Massachusetts Eye and Ear Infirmary. “We set out to better characterize the epidemiology, risk factors, and clinical outcomes of open-globe injuries in women.”

Of the more than 800 open-globe injuries reviewed, nearly 22% were in women, said Dr. Kohanim. “The average age of women with open-globe injuries was 57 years, which was significantly older than males with similar injuries, who were on average 36 years old.”

The mechanism of injury also differed between men and women. “In women, falls accounted for the majority of injuries—47%—followed by other blunt trauma at 15%.” In men, injuries associated with projectiles, sports, and sharp objects were more common.

“The most common setting for open-globe injuries in men was at work,” he said, “while most injuries in women occurred at home.”

Injuries in women also appeared to be more severe than injuries in men. “Post-operatively, only 25% of women achieved a visual acuity of 20/40 or better, compared with 44% of men,” he said, adding that this was statistically significant (p < 0.001).

“There are significant differences in baseline characteristics and the mechanism of injury of open-globe injuries between men and women,” concluded Dr. Kohanim. “The extent of the initial damage and visual outcomes are worse in women than men as well.”

Traumatic glaucoma

Not infrequently, eyes with open-globe injuries survive reconstructive surgery only to be plagued by traumatic glaucoma.

To assess the incidence of post-traumatic glaucoma, Ankoor Shah, M.D., Ph.D., and colleagues, Massachusetts Eye and Ear Infirmary, identified 382 open-globe injuries with at least six months of follow-up after surgical repair. For this analysis, traumatic glaucoma was defined as IOP greater than or equal to 22 mmHg at two or more visits or IOP elevated enough to require treatment.

“Overall, 65 eyes (17%) developed traumatic glaucoma,” said Dr. Shah. In a multivariate analysis, risk factors for developing traumatic glaucoma after open-globe injury included older age, hyphema, lens injury, and zone II injury. Zone II injury represents injury to the cornea or the anterior-most 5 mm of the sclera.

“Traumatic glaucoma was controlled with observation alone in 8% of eyes, required IOP-lowering medications in 74%, and surgery (either anterior chamber washout or a glaucoma procedure) in the remaining 18% of eyes,” he said.

After a mean follow-up of 21 months, 48 of 65 patients required no medications at the last visit, he said. “Median visual acuity also improved from hand motions of presentation to 20/60 at one year and 20/32 in two years,” he added.

“These data provide the first description of long-term management and outcomes for patients with traumatic glaucoma after open-globe injuries. Most patients can be treated successfully with medication, but surgery is a viable alternative. Most importantly, our data suggest a good overall prognosis for both visual acuity and IOP,” Dr. Shah said.

Editors’ note: Drs. Kanoff and Kohanim have no financial interests related to their comments. Dr. Shah did not indicate any financial interests related to his comments.

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